OBJECTIVE:
To evaluate the effects of a Postural Education Program (PEP) for children and
adolescents eight months after its completion.METHODS: 34 subjects were assigned to a Control Group (CG) or to an Experimental
Group (EG). Only the EG participated in the PEP, but all the subjects were evaluated
before, during and eight months after finishing the PEP. The assessment used
three procedures: (1) static posture by photography; (2) dynamic posture by
recording the execution of everyday activities (EAs); and (3) answering a questionnaire
designed to evaluate the theoretical knowledge about the spine. In order to
verify the differences between CG and EG and between the three studied periods
the following tests were used: Mann-Whitney and Wilcoxon for comparing the scores
of EAs and questionnaire, and chi-square to analyze the frequency of postural
changes in CG and EG.RESULTS: When evaluated immediately after its completion, the PEP had
a positive effect on the posture of EAs and on the knowledge about the spine.
The positive effect of the PEP was reduced eight months after its completion.CONCLUSIONS: It can be speculated that the awareness of the importance
of good posture during EAs was not effectively incorporated into the habits
of the studied group.

Healthcare professionals
have long sought ways of attenuating issues associated with poor posture, which
not uncommonly causes pain and limitation of physical and psychological abilities.
Over the past few decades, one alternative that has arisen the world over(1-9)
as a means of mitigating posture issues is the use of postural education or
"back education" programs, which, regardless of their theoretical framework,
are designed to modify everyday attitudes that lead to spinal damage(3,10).
Postural education can thus be provided to a variety of demographics, including
senior citizens, children, adolescents, and young adults(1,4-8,11-14),
as long as the theoretical and practical content of educational programs is
adapted to the distinct needs of each.

The literature
has shown that individuals who take part in postural education programs, regardless
of age, tend to effect positive modifications on posture during activities of
daily living (ADLs), and tend to exhibit improved theoretical knowledge of the
spine(6-8,10,15-18). However, few reports have focused on the issue
of whether postural teachings are actually incorporated into the daily habits
of participants of these programs and maintained later on. We believe more studies
are required to assess whether the effects of postural education programs persist
outside the context of programs themselves, and to ascertain the effects of
these programs in distinct demographics, such as children and adolescents.

Taking into account
that elementary education and social projects geared to children and adolescents
play a major role in health promotion(8,12-15,17) and assuming that
children and adolescents who acquire healthy posture habits during the development
stage tend to maintain these habits throughout the life course, the aim of the
present study was to assess the effects of a postural education program (PEP),
as a subprogram of a social project for children and adolescents, 8 months after
its completion. We speculated that, 8 months after completion of the program,
children and adolescents would be able to recognize and identify the spine,
its parts, and its functions, and maintain the natural curves of the spine in
static posture and during ADLs.

Method

The minimum sample
size was calculated as 28 for a 5% level of significance and an 80% sampling
power for between-score differences of 4 points, assuming a standard deviation
of 3.5. The sample comprised 34 male and female participants of the Projeto
Escolinhas Integradas Ayrton Senna (PEI), a social and educational project with
ties to Universidade do Vale do Rio dos Sinos. Participants were divided into
two groups: a control group (CG) of 7 children and 10 adolescents and an experimental
group (EG) also of 7 children and 10 adolescents. Mean age was 10.5±0.8
years in children and 13.2±1.0 years in adolescents. Study participants
were randomly allocated to the control (morning) and experimental (afternoon)
groups.

The criteria for
inclusion in the study were before- or after-school participation in the PEI
project, fitness for physical activity, and random allocation to the group corresponding
to the opposite of one's school. The criteria for exclusion were presence of
fractures or orthotic devices (crutches). Participation in the study was voluntary,
and dependent on the provision of informed consent by parents or legal guardians.
The study was approved by the UFRGS Research Ethics Committee and was conducted
in accordance with National Health Council Resolution 196/96.

Three assessments
- of static posture, dynamic posture, and theoretical knowledge of the spine
- were carried out at baseline, after the experiment, and at 8-month follow-up.
The total duration of the PEP was 45 days. Study outcomes were assessed at three
different points in time: at baseline, immediately post-intervention, and 8
months post-intervention.

The PEP consisted
of a back education program adapted from Souza(19) in terms of the
choice of ADLs and the language used for communication with children and adolescents.
For instance, in lesson 3, which focused on the "seated position," emphasis
was placed on sitting at school and at the computer. In lesson 5, which focused
on "standing and walking properly," emphasis was placed on carrying school supplies.
Table 1 presents an overview of the stages of the experiment
and describes the themes, objectives, and ADLs addressed in each class. Classes
lasted 1 hour each and were held twice weekly, only for participants in the
EG. Children in the CG did not receive any information and had no contact whatsoever
with the Program. This was only made possible by the fact that the children
in each group attended PEI activities in different periods (morning and afternoon).

For static postural
assessment, children and adolescents were evaluated individually, viewed from
the right side while standing and wearing appropriate clothing, using a posture
grid and a plumb line. Students were placed against the posture grid and the
plumb line was positioned as recommended by Kendall et al(20).
Students were then asked to assume whatever posture they believed to be proper,
and were photographed after doing so.

For static posture
analysis, photographs obtained from participants in both groups (CG and EG)
at baseline, after the intervention, and at 8-month follow-up were jumbled and
submitted to an independent posture specialist - who had no contact with the
study participants - for evaluation. This procedure was judged to be required
to avoid bias. The expert was asked to assess the images and note the course
of the plumb line (focusing on the shoulder and earlobe) in relation to standard
posture, which enabled assessment of shoulder posture (protracted, retracted,
normal) and head position (forward, axial extension; normal). Posture was considered
altered when the shoulder was "protracted" or "retracted" and when the head
was in the "forward" position or in "axial extension". For the purposes of this
study, the results of static posture analysis were counted merely as the total
number of cases of any postural change, regardless of whether the change affected
the shoulder or head and of whether it occurred at baseline, after the experiment,
or at 8-month follow-up.

For dynamic postural
assessment, subjects were filmed individually while performing a variety of
ADLs(21): (1) sitting on a stool, (2) remaining in sitting position,
(3) picking up one heavy object and one lightweight object from the ground,
(4) carrying these objects to a table, (5) replacing them on the ground, and
(6) writing while sitting at a desk.

Dynamic posture
analysis was performed according to the process recommended by Rocha and Souza(22),
on the same day of filming, by two study authors, each of whom was blinded to
the other's assessment to prevent bias. There was inter-rater agreement on all
observations, making independent analysis by a third investigator unnecessary.
Scores for each station ranged from four points (proper posture) to zero points
(completely incorrect posture), for a maximum total score of 24 points. The
maximum total score of each participant was used for analysis.

The educational
questionnaire sought to evaluate theoretical knowledge of the spine(8).
A specific score was assigned to each question, with the maximum total score
for the whole questionnaire being 18 points (the higher the score, the higher
the level of theoretical knowledge). The maximum score of each participant was
used for analysis.

The following nonparametric
tests were used: (1) the Mann-Whitney U, to test for differences between the
control and experiment groups at baseline, separately for children and adolescents;
(2) the Wilcoxon signed-rank test (WS), to evaluate differences between
baseline and post-intervention, baseline and follow-up, and post-intervention
and follow-up, separately for children and adolescents. These tests were applied
to the following study variables: maximum total score on the ADL circuit and
maximum questionnaire score. The chi-square test (c2) was used to
investigate the presence or absence of postural changes (frequency of postural
changes) between baseline and post-intervention, baseline and follow-up, and
post-intervention and follow-up, separately for children and adolescents. The
significance level was set at 0.05.

Results

At baseline, static
posture was similar both in the CG and in the EG, both among children (c2;
p=0.85) and among adolescents (c2; p=0.69).

Among controls,
comparison of static posture analysis findings showed no significant differences
between (1) baseline and post-intervention, both in children (c2;
p=0.85) and in adolescents (c2; p=0.67); (2) baseline
and follow-up, both in children (c2; p=0.94) and in adolescents
(c2; p=0.91); and (3) post-intervention and follow-up, both
in children (c2; p=0.71) and in adolescents (c2;
p=0.83). Therefore, participants in CG had postural issues at baseline
and continued to exhibit these issues at 8-month follow-up (Table
2).

Likewise, comparison
of static posture analysis findings among EG participants showed no significant
differences in the number of cases with some postural change between (1) baseline
and post-intervention, both in children (c2; p=0.13) and in
adolescents (c2; p=0.07); (2) baseline and follow-up, both
in children (c2; p=0.30) and in adolescents (c2;
p=0.20); and (3) post-intervention and follow-up, both in children (c2;
p=0.47) and in adolescents (c2; p=0.32). Although there
were no significant changes from baseline to the post-intervention period were
found in the experiment group, a decline in the number of cases of postural
changes did occur, that is, some PEP participants did show improvement in postural
alignment (Table 2). Eight
months after completion of the PEP, however, the number of cases of postural
changes in the EG had increased (Table
2).

There were no significant
differences between controls and experimental participants in dynamic posture
at baseline, neither in children (U; p=0.08) nor in adolescents (U; p=0.66).

Comparison of dynamic
posture assessment findings in the CG revealed no significant differences between
baseline and post-intervention (WS; p=0.22 and p=0.06
for children and adolescents respectively); baseline and follow-up (WS;
p=0.14 and p=0.11 for children and adolescents respectively);
or post-intervention and follow-up (WS; p=0.63 and p=0.26
for children and adolescents respectively). Therefore, CG participants continued
to carry out their ADLs as they did at baseline (Table
3).

Conversely, comparison
of dynamic posture assessment findings in the EG revealed differences between
baseline and the post-experiment period (WS; p=0.001 and p<0.001
for children and adolescents respectively) in how subjects carried out their
ADLs. Similar differences were also found between baseline and follow-up (WS;
p=0.013 and p=0.021 for children and adolescents respectively)
or between post-intervention and follow-up (WS; p=0.008 and
p=0.002 for children and adolescents respectively). In the experimental
group, all differences in performance of ADLs at 8-month follow-up (that is,
8 months after conclusion of the PEP) were in the sense of returning to baseline
postural inadequacies (Table
3).

Pre-PEP theoretical
knowledge of the spine was similar in CG and EG participants, both children
(U; p=0.32) and adolescents (U; p=0.85).

Among controls,
theoretical knowledge of the spine did not change significantly between baseline
and post-intervention (WS; p=0.06 and p=0.43 for children
and adolescents respectively); baseline and follow-up (WS; p=0.12
and p=0.08 for children and adolescents respectively); or post-intervention
and follow-up (WS; p=0.26 and p=0.23 for children and
adolescents respectively), showing that CG participants had the same theoretical
knowledge of the spine throughout the study period, as was to be expected (Table
4).

Among participants
who took part in the PEP, however, theoretical knowledge of the spine changed
significantly between baseline and post-intervention (WS; p=0.001
and p=0.001 for children and adolescents respectively); baseline and
follow-up (WS; p=0.045 and p=0.041 for children and
adolescents respectively); or post-intervention and follow-up (WS;
p=0.038 and p=0.042 for children and adolescents respectively).
In the experimental group, all differences in theoretical knowledge at 8-month
follow-up (that is, 8 months after conclusion of the PEP) represented reductions
in questionnaire score - meaning that participants returned to their initial
level of knowledge on the spine, its parts, and its functions (Table
4).

Discussion

Pre-PEP static
posture assessments showed that nearly all children and adolescents in the sample
had some sort of postural change. This finding is consistent with those of Rosa
Neto(21) and Detsch et al(23), who reported high
prevalence rates of lateral and anteroposterior postural deviations in student
populations.

However, qualitative
observation of the results in Table
2 shows that, from baseline to the immediate post-intervention period, there
appears to have been a decline in head and shoulder deviation from the plumb
line, which suggests that the PEP effected a "positive postural change" among
EG participants, because results were obtained immediately after completion
of the program, when self-perceptions of posture and understanding of the new
concepts addressed in class were still fresh in participants' minds. Conversely,
comparison between baseline and 8-month follow-up and between the immediate
post-intervention period and 8-month follow-up showed a "postural change" in
the opposite direction - that is, the positive effects detected immediately
after completion of the program had faded, and participants had returned to
their incorrect pre-PEP postures (Table
2). Nevertheless, these results were not supported by statistical analysis,
which showed no statistically significant difference between the frequency of
postural changes at each of the three stages of the study.

Bearing in mind
that the growth period may have affected the results of static postural assessment,
the present study was subject to one major limitation: no specific tests other
than chronological age were used to control for puberty. Hence, some children
in the study might have already reached puberty, whereas some adolescents might
have not. However, any potential effects of this limitation are mitigated by
the finding that results were similar among children and adolescents.

In addition to
the growth process, motivation is another factor that is likely to have influenced
the results of the PEP as measures by static posture assessment in the post-intervention
stage and at 8-month follow-up. Tresca and De Rose(24) and Scalon
et al(25) stress that motivation is a driver of learning,
helping learners channel perceived information into behavior and leading humans
to action or - inertia - in other words, motivation is the reason why one chooses
to do something or maintain one's current state. Hence, motivation played an
essential role in implementation and execution of the PEP, as it is a decisive
factor in the learning process: motivation is responsible for inertia or action
in every activity of life.

It is important
to stress that at no point did the PEP attempt to correct existing postural
changes: its sole objective was to teach proper posture for performance of ADLs
and the importance of following the slogan "tug on the plumb line and smile"
as a means of maintaining natural spine curvature during ADLs. Therefore, static
posture assessment was performed only to evaluate whether subjects in the experimental
group, after taking part in the PEP, would try to keep their static posture
realigned in response to changes in the content addressed in class.

Unlike the results
of statistic posture assessment, the differences in dynamic posture assessment
from baseline to the post-intervention period suggest that the positive changes
in ADL performance detected immediately after completion of the PEP were indeed
due to the effects of postural education, as expected. Méndez and Gómez-Conesa(6)
evaluated the effect of a postural education program on 106 schoolchildren aged
9 years and concluded that participation in the program improved theoretical
knowledge and performance of ADLs at school. In Brazil, Ritter(18)
led a back education program for 61 students with a mean age of 15 years. For
assessment of ADL performance and comparison between baseline and the post-experiment
stage, the author used the protocol developed by Rocha and Souza(22)
(as did the present study); PEP participants showed significant improvement
in all ADLs, whereas controls did not change their patterns of carrying out
ADLs.

Although it is
well established in the literature that back education programs tend to effect
positive behavioral changes in terms of adoption of proper posture during ADLs
immediately after completion of such programs, few studies have attempted to
identify whether these positive changes are permanent. In the present study,
differences in dynamic posture from baseline to follow-up and between the immediate
post-intervention period and follow-up (Table
3) are due to the reduction in ADL test scores, which shows that an 8-month
period of no guidance on or reinforcement of newly learned activities, which
could have helped ensure real assimilation of good postural habits by participants,
probably had a negative impact on the long-term effects of the program. Therefore,
the fact that PEP effects were "transient" in this study may have been a limitation
of this method. On the other hand, the findings of Cardon et al(13),
who reported medium-term positive influence of a postural educational program
in fourth- and fifth-graders, encourage further studies of this nature.

In light of these
distinct realities, one suggestion for fostering use of PEPs and possibly minimizing
delayed negative effects would be implementation of regular "refresher" events
- that is, after having taken part in a PEP, participants would be invited to
return periodically (before 8 months) and experience again, perhaps in a single
session, the body and posture activities experienced during the PEP. Weineck(26)
notes that breaks in regular exercise practice lead to a slow extinction of
motor patterns, even after a short time. Therefore, long periods spent with
no follow-up or no practice or experience of the activities taught would lead
to a progressive loss of motor patterns. Unless renewed periodically, automatic
movements are soon lost from a mechanical, physiological and conditioned reflex
standpoint, which would account for the decline in knowledge acquired during
the PEP when participants were assessed at 8-month follow-up.

The fact that participants
in the EG had the highest number of right answers on the study questionnaire
on comparison between baseline and the post-intervention period (vs. baseline
to follow-up or post-intervention to follow up) (Table
4) also provides evidence of the positive effects of the PEP immediately
after its conclusion. Similar findings were reported by Candotti et al(8)
and Cardon et al(15), who found that children who attended
a PEP learned to understand and identify the spine, its parts, and its functions.
However, in the present study, 8 months after completion of the PEP and with
no attempts at reinforcing teachings during this period, participants got fewer
answers right when administered the assessment instrument again, which reveals
a need for "refresher" classes and other learning aids.

Faced with these
findings, we believe it is important that Postural Education Programs continue
to be implemented, and their effects studied, including long-term assessment,
so as to ascertain the persistence of the knowledge acquired by participants
of these programs. It would be interesting for new PEPs for children and adolescents
to be held; however, after the completion of these programs, regular reinforcement
of new knowledge, by means of monthly activities such as lectures or postural
workshops, is required Such activities might have ensured learning and assimilation
of the contents of the PEP.

In short, our results
suggest that, immediately after its conclusion, the PEP had a positive effect
on theoretical knowledge and on the posture adopted while carrying out ADLs.
However, at least in the present study, this effect did not extend to the follow-up
period. Therefore, 8 months after conclusion of the PEP, its participants showed:
(1) no knowledge of and inability to identify the spine, its parts, and its
functions; and (2) inability to maintain the natural curves of the spine, whether
in static posture or during ADLs. These findings suggest that the theoretical
content of the program and knowledge of the importance of maintaining good posture
during ADLs were not truly incorporated into the habits of children and adolescents;
in other words, 8 months after completion of the program, children and adolescents
had not assimilated the new knowledge it was meant to provide.